Disclosure Form

 

*Please read and sign below*

** You must print this out and sign this copy an email it to Hello@newheightswv.com

I hereby authorize the release of information necessary for this application to New Heights Church, so that my request for assistance can be processed.

I agree to all terms and conditions outlined by New Heights Church in this request, and by God’s grace, I will abide by them.

I certify that the information I have provided is true and correct to the best of my knowledge, and that all income is reported.

I understand that New Heights Church may verify the information on this application and that deliberate misrepresentation of information, false information, or incomplete information may subject me to denial of assistance, services, and/or disqualification of current and future assistance.

I give New Heights Church permission to discuss my case with other agencies, businesses, Churches, attorneys, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible with these entities.

I understand that the benevolence request process may involve potentially uncomfortable questions and analysis of my situation and spending habits.

I will accommodate all requests from New Heights Church for any additional information deemed pertinent to this case.

By signing below, I state that I have read, understood, and agree to the policies above regarding the use of my information and that the above information is accurate and true.

Print first and last name *
Print first and last name
Date *
Date

** You must print this out and sign this copy an email it to Hello@newheightswv.com